Provider Demographics
NPI:1902055650
Name:RODRIGUEZ, SHANTAE (PA)
Entity Type:Individual
Prefix:
First Name:SHANTAE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-2478
Mailing Address - Fax:631-444-3919
Practice Address - Street 1:STONY BROOK MEDICINE EM
Practice Address - Street 2:100 NICOLLS ROAD, HSC, LEVEL 4, ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-444-2478
Practice Address - Fax:631-444-3919
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012566207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012566OtherLICENSE #
1079871OtherNCCPA CERT.#